Usually this involves the inability of the liver to get rid of bile, as with gallstones or a tumor blocking the bile duct;
liver can't release bilirubin as a component of bile and it releases it back into blood instead.

What is conjugated bilirubin?

This is joined with gluconeride in the hepatocytes. Associated with obstruction of the biliary system (stones). Posthepatic.

What is unconjugated bilirubin?

This is caused by excessive hemolysis. Prehepatic.

What is mixed bilirubinemia?

This is associated with liver cell necrosis and destruction of liver parenchyma. Hepatic.

What is brown, foamy urine a symptom of?

Viral Hepatitis
-conjugated bilirubin is water soluble and is excreted in urine.

Alcoholic liver disease characterized by infiltration of hepatocytes by fat or lipid material; reversible, does not affect biochemical function of hepatocytes until well advanced. (alcholism is not the only cause)

-decreased fatty acid oxidation and decreased export of lipioproteins from the liver
-diets high in fat can overwhelm the ability of the liver to process fat (foie gras)

What are esophageal varicies?

Tortuous, highly dilated veins in the esophagus that can hemorrhage; caused by HTN in the hepatic portal system.

What is the hepatic portal system?

The venous drainage from the entire GI tract.

What is a portal system?

Connection of 2 capillary beds:
In a portal system, blood leaves the heart, circulates through arterial system and arrives at a capillary bed in the GI system --> venous drainage continues to the liver where another capillary bed is encountered within the liver --> the liver is then drained by a vein that leads back to the heart.

Is the hepatic portal system low or high pressure?

Low pressure (5-10 mmHg).

What is hepatic portal system HTN?

Liver becomes diseased --> flow of portal blood is impeded --> pressure increases (>12 mmHg).
-Symptoms of this dysfunction are related to the structural connections that exist between this portal system and systemic circulation.

Portal HTN --> shunting of blood into splenic vein --> splenomegaly and hypersplenism from prolonged transit time of blood through the spleen
-hypersplenism - decreased life span and decrease in number of blood cells, leading to anemia, thrombocytopenia, leukopenia

So, the major complications of portal HTN and opening of collateral channels are:

Biliary blockage [posthepatic] [100% conjugated]
-both intrahepatic and extrahepatic blockages can occur
-adverse affects of digestion of fats and fat-soluble vitamins due to a lack of bile can lead to jaundice

What is the type of jaundice associated with cholestasis?

Obstructive Jaundice

Obstructive Jaundice is also often seen with this disorder:

Carcinoma of the head of the pancreas

Biliary blockage of the duct can result in this:

Reflux of bile back into the pancreas --> pancreas digests (emulsification of fat in cells by bile)

Caused by many years of recurring bouts of necrosis of liver cells and repair by fibrosis with disorganized regeneration of liver cells.
-nodular pattern of liver
-Dx grossly by liver's appearance
-whole liver or regions can be affected

What does it mean if IgM and IgG specific antibodies are elevated for months after symptoms have gone away?

This means virus is still present and the immune system is still defending the body against it.

What is Heptatitis B Virus (HBV)?

-many phased, serious disease
1)subclinical - evidence of the disease without manifest symptoms - Recovery
2)acute infection - Recovery
3)fulminant - followed by death (entire liver is destroyed)
4)heathy carrier
5)chronic non-progressive or persistent infection in which the patient recovers or moves to next step
6)chronic active that progresses to cirrhosis or hepatocellular carcinoma and death (fibrosis and liver is destroyed)

What are lab markers for HBV?

-First, Serum IgM-antiHBV
-then, Serum IgG-antiHBV
** persistence of IgG-antiHBV may be the only serological indication of viral infection in persistent infection or in a healthy carrier - MAY PERSIST FOR LIFE

Yes - smouldering or persistent infection followed by recovery
-develops in <10%
-asymptomatic in 75%
-25% develop chronic active hepatitis and may progress to cirrhosis

Chronic hepatitis has a strong correlation with:

This has a strong correlation with rare development of hepatocellular carcinoma (unwanted cell replication).

What is hepatitis D Virus (HDV)?

-incomplete RNA virus
-requires HBV for replication
can occur simultaneously or as a superinfection following HBV

What characterizes HDV from HBV?

-more severe symptoms
-progression to cirrhosis is more accelerated

What is Hepatitis C Virus (HCV)?

-RNA virus
-acquired by blood transfusion or sexually

What is the clinical presentation of HCV?

-similar to HBV
-acute phase is less severe than HBV
-UNLIKE HBV, may smoulder for years with no symptoms
-UNLIKE HBV, tends to progress to chronic hepatitis (50%) and half of these patients develop cirrhosis

What are lab markers of HCV?

-serum IgM-antiHCV and serum IgG-antiHCV present throughout course of disease

Is it possible to differentiate types of hepatitis virus infection histologically?

No - it is impossible to distiguish one from another morphologically.

Where is the pancreas located?

Retoperitoneally in the upper abdomen on the left (behind the peritoneum).
-disease associated with pancreas causes referred pain to the back.

What are the digestive enzymes produced by the exocrine pancreas?

amylase
lipase
peptidases - trypsin, chymotrypsin
bicarbonate

Enzymes of the pancreas are secreted as:

proenzymes
-they become activated by enteropeptidases and increased pH in the duodenum

What are the major diseases of the pancreas?

-pancreatitis
-tumors

What is pancreatitis?

Acute or chronic inflammation of the pancreas; usually a sterile chemical inflammation (no pathogens).
-tissue destruction is caused by digestive enzymes released

What is a very mild form of pancreatitis and rarely diagnosed?

Acute edematous pancreatitis

What is a serious form of pancreatitis with a high mortality rate?

Acute hemorrhagic pancreatitis

The premature activatio of pancreatic enzymes results in:

autodigestion of the pancreas

What are three conditions that can cause acute pancreatitis?

1)obstruction of main pancreatic duct, frequently by gallstones with reflux of bile
2)injection of bile or other chemicals into the pancreatic duct
3)mechanical disruption of the pancreatic acinar cells (seatbelt trauma)

What is the pathology of acute hemorrhagic pancreatitis?

-massive edema, hemorrhage, and necrosis of tissue
peritoneal irritation or chemical peritonitis occurs due to leakage of enzymes
-serum levels of lipase and amylase are high